12
Minimally Invasive Endoscopic
Sinus Surgery with Powered
Instrumentation
History
Rueben Setliff was the first physician to successfully demonstrate that powered cutting tools could be used with precision, control, and safety in the nose and the paranasal sinuses in humans.1 While seeking to improve the surgical approach and the outcomes of nasal sinus surgery, he recognized that the precision that controlled powered cutting could afford a surgeon was available to others but had not been examined and attempted in the field of otolaryngology. To that end, he began to use equipment that was available and had been designed for use in the small joint spaces of the hand and the temporomandibular joint (TMJ). In the late 1980s and early 1009s the first efforts offered a great deal of success and demonstrated that the equipment would work but that the requirements of the tissues in the paranasal sinuses would demand a more specifically designed tool. Setliff then began to engage medical instrument companies to improve and promote their instrument design. Through his pioneering vision and his tireless effort to seek the medical instrument establishment’s acceptance of this procedure, we as physicians today have an entirely new tool to use in the field of nasal surgery.
The application of power to a surgical procedure is not new by any standard, but over time the advent of a series of new and more progressive technical improvements in specifically nasal surgery has occurred. The most obvious examples can be appreciated with a review of the application of power and optical improvement in the field of otologic surgery. The use of the dental engine and the advent of the use of the operating microscope appeared almost at the same time and were met at first with only lukewarm acceptance. However, within a short period it was obvious that surgical procedures were improving with the new tools, and surgeons began to understand that previously established limits were technical barriers only and that new limits could be explored.
The introductions of optical endoscopes and powered cutting tools in surgery on the nose and paranasal sinuses seem to be directly parallel. The ability today to proceed in a more defined, surgically clean field with ever increasing precision and delicacy allows surgeons great choice with respect to tissue preservation.
Type of Cutter and the Position of the Cutter
The important aspect of what Setliff accomplished was the choice of a cutter that had the blade face positioned so that the opening of the cutter was able to be seen by the operator through the endoscope at the same time he or she was operating. The previous choice had involved cutter designs that employed end-mounted cutters. These were not effective because of the viewpoint that the surgical field presented. The limits of the exposure do not allow the operator to see the end of the cutter during the actual time that tissue is being cut, and therefore the surgeon was cutting blindly.
Development of the Micro-Debrider Tool
Micro-Debrider
The first Micro-Debrider (Stryker Leibinger, Kalamazoo, MI) was adapted from a tool produced for use in small joint arthroscopy in the wrist and the TMJ. It is our good fortune that the tool was so nearly ideally designed for the newly identified use. It required very little design change and was rapidly able to be approved for use in this new area by appropriate government agencies.
Suction
The real breakthrough that allowed the cutting tool to work and achieve early success and usefulness was the continuous suction at the working end of the tool. The suction allows the tool to remove tissue and blood from the field as the surgery proceeds. This allows the surgeon to work with two hands. One hand holds the working tool, while the other hand holds the endoscope and controls the surgical field of view. Although the two-handed approach had been promoted by others, it previously had been difficult to put into practice because of the technical demands the procedure requires of not only the surgeon but also the operating room team and staff.
The continuous suction at the distal tip of the cutting instrument meant that the surgeon could now operate and clear the field at the same time and remain in control and in full view of the procedure at all times.
Irrigation
The problem that this system had in its early development was its lack of effectiveness with respect to tissue removal. The instrument could clog with tissue that was being cut free and removed from the field. This presented many difficulties in the early days of the development of the Micro-Debrider tool. When the suction became blocked, it failed to present new tissue to the cutter and failed to remove cut tissue from the blade. The failure of the suction system was one problem that the surgeon needed to keep in mind because it appeared to be so subtle that it was often unrecognized.
This problem required an immediate fix and resulted in a field repair.
STOPCOCK SYSTEM
The first fix to this problem was the insertion of an inline three-way stopcock that allowed the assistant to cut off the suction and direct a stream of hand-pressurized water to the clogged instrument. This system worked fairly well, but it required the assistant to fill and replace the syringes often and to divide his or her attention between the operating field and the stopcock system while the surgeon was operating. This system is still available. It fits the requirements of the individual surgeon.
PRESSURE SYSTEM
The importance of maintaining the Micro-Debrider tool in its best state of function led to the development of the pressurized irrigator and tissue trap system. This system places a large volume of irrigating solution under pressure via a pressurized infusion bag. The stopcock was replaced by a two-way lever valve and inline tissue trap. The tissue trap allowed the system to collect two separate specimens and submit them for pathological examination. The advantages are that the system remains closed and the nursing staff does not come in contact with tissue or fluids.
SELF-IRRIGATION SYSTEM
The self-irrigation system, which has evolved into its third generation, has addressed many, but not all, of the problems associated with clogging. The ideal system setup includes a self-irrigating handpiece as well as a pressure irrigator.
Tissue Trap
The advent of the tissue trap has allowed the surgeon to continue to send the entire resected specimen to the pathologist rather than representative samples. These traps are widely available and are always mounted in the suction line after the cutter. They may be placed in the suction canister as well as in the field. It is good medical practice to obtain tissue for study, whether using microshavers or cutters.
Cutters
The designs of today’s cutters all feature a partly forward-facing cutter window and a revolving inner cutter blade with variously shaped cutting edges.
Basic blades come in different diameters. The appropriate size is determined not only by the age of the patient but also by the size of the nasal and sinus cavities. The different blades allow careful and thorough access to these areas. Basic blades are straight. They vary with respect to their shape and size, as well as the location and dimension of the cutter window. The choice depends on the specific application.
Burs
Burs have great use in complex procedures such as intranasal removal of osteomas, removal of heavy bone around the front face of the sphenoid sinus and bone thickened from chronic infection, and the treatment of the frontal sinus duct. They also have great application for the plastic surgeon in bone remodeling.
Image-guided Triplanar Navigation
The availability of the multiplanar intraoperative tracking system (VTI, General Electric System, Lawrence, MA; Micro-Debrider, Stryker Leibinger, Kalamazoo, MI) has given surgeons new margins of safety. These systems are all based on the use of a high-speed computer and a system for reference to the patient intraoperatively. They require the patient to have had a super-high-resolution CT scan with a registration device in place prior to the operation. Surgical instruments are linked to the computer, and the computer displays a real-time image of the location of the cutting tool. This location is referenced in simultaneous axial, coronal, and sagittal images on the monitor screen. In the case of paranasal sinus surgery, this allows the surgeon to identify the location of surgical instruments. Accuracy is ~0.25 mm. This is important because of the proximity to the orbital contents, carotid siphon, and intracranial space.
Minimally Invasive Endoscopic Sinus Surgery
Most nasal and sinus surgical procedures in the United States are performed in an ambulatory surgery center. The procedure as outlined below can be modified depending on the needs of the particular surgical setup. However, the requirements that are noted are very important and if not respected will lead to results that differ from the experiences presented.
Anesthesia
The anesthesia of choice for this operation is a combination of regional nasal blocks, topical local anesthesia, and IV sedation or general inhalation techniques. The choice of IV or general inhalation techniques is personal and should be discussed with the patient before the operation. However, the use of regional nasal blocks and topical local anesthesia is required.
Oxymetazoline
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